Mulago Hospital, Kampala

As promised in my last post let me tell you a little more about Mulago hospital and the project Cairdeas is hoping to support. Founded in 1913 initially to treat infectious diseases, including sleeping sickness, it soon grew to an unwieldy level until a new hospital was opened in 1962 and refurbished in 1987 . It is the main referral and teaching hospital for Uganda and hosts the medical school as part of the Faculty of Medicine at Makerere University. There is also a nursing school and institutes of public health, cancer and infectious diseases. Makerere is a prestigious University which grew out of the University of East Africa; becoming independent in 1970. Medical students have been taught palliative care since 1993 with a clinical rotation to Hospice Africa Uganda (HAU) The Mulago palliative care team began in 2006 with the appointment of 4 nurses who had been trained at HAU. Here they are hosting a visit from a team from Rwanda. Do you recognise Grace, left front row, who featured in a previous BLOG and is the first nurse in Rwanda to be trained in palliative care? The team have achieved much in a year but are desperately needing more resources and senior medical support. We are looking to form a much more comprehensive service and be able to offer it as a centre of excellence and a 'model' for colleagues in teaching hospitals and universities elsewhere in Africa. It is a big challenge but also a great opportunity.
One of the most successful recent initiatives has been children's palliative care and I want to take you with me to the cancer treatment ward. Caroline Rose, a paediatric palliative care nurse from the UK along with Dr Justin Amery, nurse Charles from Hospice and joined by teachers / play facilitators have worked with the oncology teams to make a difference to the lives of the children and their families. There are murals on the walls, a new classroom, morphine (can you spot the bedside bottle?) and other drugs made available, support for families and helping with the treatment costs of children with Burkitt's lymphoma via an Irish fund. The day I visited we were able to give out hand-knitted teddies sent from the UK. I wish you could have seen the excitement and joy such a simple gift engendered. Here is Irene (see left) who recently featured in a story in the weekly Guardian, proudly clutching her red teddy. She has been receiving treatment for much of the past year. Her family don't live in Kampala and cannot afford the expenses her illness has brought. The Hospice team have been able to not only support her treatment, but also to make sure she has pain control, a mattress to sleep on, food to eat, and the chance to keep up with her schooling. David (see right) has also had help with medication and treatment. Despite his illness and the need for strong morphine painkillers, you can see his delight and joy in this picture with Caroline. Quality of life shown in a smile. Adding life to days not days to life..........

Kampala visit

Greetings from Uganda. You may have been seeing something of this beautiful country on the news recently as it has just hosted CHOGM and the Queen!!! For the uninitiated, this is the Commonwealth Heads of Government Meeting and was opened by Queen Elizabeth who was accompanied by Prince Philip, and Prince Charles. Dr Anne Merriman was invited the meet the Queen and here she is dressed in her African finery with her MBE medal! Not to be outdone; wee Mary, whose Mum works at Dr Anne's shows off her Scottish teeshirt too!There has been great excitement here as it was 1954 when the Queen last visited and a beautiful wildlife area named after her; Queen Elizabeth park. Uganda is hoping many will want to come in the wake of the Queen and I can add my wee mention that the 'Pearl of Africa' is well worth a visit.

The downside was endless motorcades, roads closed and work grinding to a halt!!! Despite these challenges I have been able to meet many of the people involved in the project here in Kampala. I am in discussion about Cairdeas supporting the development of a Palliative Care Unit within the Department of Internal Medicine at Mulago Hospital and Makerere University. Mulago is the main teaching hospital and also hosts the cancer institute for Uganda and the infectious diseases center. It is the major university teaching hospital in Kampala and Uganda; and there is huge need for palliative care for the many patients and families who pass through the doors. There is an existing nurse team but little medical support. We also need to support training, research and to raise the profile of palliative care throughout the university and hospital. I will tell you more of the hospital and it's needs in a later BLOG and introduce you to some people there. I have been very encouraged by the willingness of so many to meet, plan and offer support for a Palliative Care Unit; including colleagues such as the Dean of the Medical school, Head of Internal Medicine, Ministry of Health officials and Hospice Africa Uganda staff. You can see some of the Ministry colleagues on a visit to HAU; and they have consistently supported palliative care in Uganda. It was the first country to list palliative care as an essential clinical service and to approve training for morphine nurse prescribers.

All in all this is an exciting project and we hope to have some definite plans in place soon with a possible start date of June 2008. If you want to support this please let us know as adequate funding will be a crucial factor in making dreams a reality.

Lastly, here is a photo taken by a friend and Cairdeas supporter, John Daniels, of Lake Albert. So beautiful!!

World Hospice Day

October 6th 2007 is a day to highlight issues of hospice and palliative care worldwide. There will be many many events across the globe, with details on http://www.worldday.org/ This year the theme is 'Across the ages - children to older people', and raises issues of access to care. A new report also highlights the scandal that many many people have not even basic pain control. Called 'Access to pain relief - an essential human right', it can be downloaded via this weblink. http://www.worldday.org/documents/access_to_pain_relief.pdf Many messages of support have been received such as this statement by the Irish rock star and campaigner Bono, "In the poorest countries, where so many people are fighting for their lives, the conditions of death don’t get much of a look in. But how we care for the sick and dying is surely a litmus test of our humanity. Just as we fight for equality in life, we should fight for equality in death.”

Let me give you a flavour of the problem. A colleague in Africa shared last year the tragedy of caring for patients when there is no access to analgesia. A young woman with severe pain due to her progressive breast cancer asked over and again for help. Her doctor had very little to offer and eventually had to admit this to her. She thanked him and went home to take her own life. We can only guess at the despair and suffering that goes unacknowledged and unsupported. Yet we have seen in Uganda, Kerala and many other countries that pain relief can be made affordable and available. (see the picture of oral morphine in Hospice Africa Uganda and Abdul Aziz, a patient in Kerala whose pain was controlled with oral morphine) A few months ago I had the privilege of spending time in India with journalists from the New York Times; Donald G McNeil Jr and Ruth Frensom, who were researching the issue of lack of access to morphine. The 2 articles appeared on the front page of the New York Times Sept 10th and 11th. Please read them by accessing the links below; and make sure you watch the audio-visual. It is such an excellent overview entitled 'Drugs banned; many of the world's poor suffer in pain.'

http://www.nytimes.com/2007/09/10/health/10pain.html?_r=1&oref=slogin
http://www.nytimes.com/2007/09/11/health/11pain.html

Finally, here is Charles. He works as a clinical medical officer in Sierra Leone where there is a palliative care service called Shepherd's Hospice. Charles and his team face huge problems; including no oral morphine, lack of electricity, prohibitively expensive fuel and a ratio of 1 doctor to 54,000 people.

Let us do all we can to raise the awareness of these issues and to support Charles and many like him who are seeking to overcome the challenges and ensure care is available to all who are in need.

Nairobi and Malawi

September 2007 saw more than 400 delegates from over 30 countries gather in Nairobi, Kenya for the 2nd conference of the African Palliative Care Association (APCA). It was an exciting few days with delegates from such different countries having a chance to learn, share and plan. The energy and commitment shone through - but also the huge challenges facing those trying to ensure palliative care reaches those who need it most. The 'giants' of African palliative care were acknowledged and thanked (see left). East and South Africa have seen the greatest palliative care developments but there were delegates from West Africa and the francophone countries that were beginning to see changes. The delegation from Rwanda (see left) took time to plan together with a very proud Grace (front wearing white) who is about to graduate with a Diploma in Palliative care from Nairobi/Oxford Brooks; the first nurse to do so in Rwanda. Across the continent morphine availability and accessibility remain major barriers; as do other resources and training.

I then made the journey to Malawi with my 2 colleagues Prof Scott Murray and Dr Dorothy Logie. We were facilitating a Master trainer's course in the capital Blantyre; and supported by funding from the Scottish Executive. The course had been jointly arranged by the Palliative Care Association of Malawi (PCAM) and the Ministry of Health and sought to train the leaders in Malawi to teachers and trainers. It was a challenging week but inspiring and rewarding to work with such committed participants. They represented the key people who will take the palliative care agenda forward in Malawi - and very encouragingly, included senior participants and facilitators from the Ministry of Health. This government support will be crucial. We were also joined by Fatia Kiyange from APCA as a co-facilitator which again represents wider African support.

Malawi faces many challenges with significant HIV/AIDS prevalence, high maternal mortality, scarce resources, few doctors and a low GDP. Despite these challenges there is much being done in palliative care. There is an agreed manual for training and plans to include palliative care across the health sectors, including home based care. Making sure this training makes a difference in the villages and hospitals remains a challenges but we wish our colleagues well in Malawi as they seek to address these needs. It is a beautiful country - and the place where the idea for Cairdeas was born. You can see me under the baobab tree where the first Cairdeas vision was drawn up; maybe even the same tree that David Livingstone sat under! Lastly, sunset over the Shire River to the sound of hippos.

travel in uganda

Come with me on a short trip to Uganda. The main base for Hospice Africa is in Kampala - the capital city; built across 7 seven hills. Uganda is frenetically preparing for the Commonwealth Heads of Government Meeting (CHOGM) with seemingly every road dug up and a forest of shrubs and plants ready for planting - if only it would stop raining. Several Ugandans asked me whether the Queen would be happy with the preparations and I had to confess I am not often chatting with HRH. Getting around is by minibus taxi known as 'mutato' with most journeys culminating in the taxi park. For the more adventurous there are the motorcycle taxis or 'boda bodas'. No helmets and a dusty ride but at least you can weave through the traffic jams. Several hours down the busy highway towards Rwanda and the DRC, in Mbarara, there is a very different model for Hospice Africa. Here a vehicle laden with medicines, antiseptic wash, morphine and children's toys leaves early in the morning. Stops are made along the 74km main road towards the district clinic where patients waited for their monthly review. Clinics under the banyan tree - often with a curious audience. We drove past the daily events of life in Ibanda district; boys dragging their heavy loads of matoke (staple diet of steamed bananas) to market and car mechanics setting up shop in the street. Martha and her team were not only offering a great clinical service but also were concerned with the financial challenges, family support and spiritual care. Holistic care in action. Our last patient was seen up a dirt track in the dark - and a sobering site as a desperately poor mother tries to keep her family together despite her illness. No sign of food or fire for the night - thankfully the team were able to offer practical help, clinical care and compassionate concern.

Did you sense some of the realities of palliative care in Africa? I is amazing to see how much has been achieved across Uganda with the support of the government and many many people who are committed to bringing comfort and care. We are discussing an exciting and challenging project to support the training and teaching in Kampala. Next week I will be at the African Palliative Care conference in Nairobi where the theme is 'keeping it real'; so watch out for the next post.

Meanwhile my favourite portrait of the inspiration and founder of Hospice Africa, Dr Anne Merriman. Surrounded by kittens and puppies as ever!

uganda

Greetings from the 'Pearl of Africa' It is good to be back and to have such a warm welcome from Dr Anne Merriman and the staff at hospice Africa Uganda. This was one of the early palliative care services in Africa (1993) and sought to provide a model for cost effective care in this continent, as well as offer care to Ugandans. (see BLOG 11/10/06) One of their objectives is also to support palliative care in other African countries; and this is done by education and training support as well as exchange visits. Here you see Dr Anne with 2 nurse colleagues (Funmi and Kuye) from Ibaden in Nigeria. They have a very new palliative care programme and are receiving support and training from Hospice Africa. It was so encouraging to attend a Palliative Care Association of Uganda update and see how much has been achieved since 1993. I have been doing some teaching at the Hospice as well as exploring future ways Cairdeas can offer support.

Let me take you to meet a lady we visited with the Jinja Hospice team. Perpetua lives in a rural setting with her family. You can see her young grandson outside the 'kitchen'. She has been ill for some time and had a miserable experience of uncontrolled pain and expensive visits to hospital with little benefit. With the support of the Hospice team; who can assess and prescribe free drugs including oral morphine; her pain is under control and she is happy to be at home. She wanted to pray for us as she felt God had sent us to help her and give her family support. Here she is reading some verses from her bible and giving thanks for all the help she has received. It is good to be reminded of our core values and purpose in palliative care and to consider the many many people who are not able to access the help that they need.

I hope to visit one of the other sites for Hospice Africa this week so will tell you more of life in Uganda in my next BLOG.


Highlights so far have been many but include a very African church service led by a famous children's choir, Watoto, who are all orphans (many as a result of HIV/AIDS). Dr's Peter and Trish Kiehlmann were also with me on a visit from Aberdeen - small world?

travels

I am finally back in the UK after travelling east with various stops for both work and catching up with friends and family. Thanks to all who have given me a home and welcome on the way. I have met friends from as long as 20 years ago as well as made new friendships and colleagues.

It was great to meet up with Dr Rosalie Shaw and Dr Cynthia Goh again in Singapore. Over a wonderful Chinese meal we had some very interesting discussions re possible areas of future work. Please look at the Asia Pacific Hospice Network's very good website for more information. http://www.aphn.org/
The temperature change from Delhi at 46 degrees C to Sydney and Auckland at 13 was a real shock; necessitating the purchase of thermals!! Katherine is a Cairdeas Trustee and treasurer and we had time for work - but she is also Mum to wee Ruari who is also my godson. Here is Mum and Dad (Rich) with Ruari in the Blue Mountains. I also had great fun with my niece Naama. Kitty (my sister) and Pat are presently in Auckland studying and falling in love with New Zealand all over again. It is such a beautiful country.
Farther east I was introduced to the 'biggest of everything' in Texas and was delighted to accept an invitation from Dr Suresh Redddy to visit the MD Anderson palliative care service in Houston and led by Dr Eduardo Bruera. Not only are they a leading model for palliative care in the USA but also committed to supporting sustainable palliative care across the world. The IAHPC is also based in Houston and it was a pleasure to meet Liliana De Lima, who is the Executive Director. This is an excellent organisation which does much to support palliative care in many parts of the developing world. Please check out the website. http://www.hospicecare.com/
My niece's name, Naama, means Grace in Arabic; and this is such an amazing concept. How do we know the reality of grace in our own lives? I watched the current film about the UK struggle to abolish the slave trade, Amazing Grace, on my transatlantic flight. If you have not seen it please do and tell me what you think. The words of the title song are so powerful, here is a link to remind you. http://www.amazinggracethemovie.co.uk/song.php I found the film a powerful reminder of our responsibility to seek justice in our world. What can we do to make this world a better place - to see justice in the midst of such injustice?
There is a verse in the book of Micah that says 'He has showed you, O man, what is good. And what does the Lord require of you? To act justly, and to love mercy and to walk humbly with your God. For Cairdeas we seek to challenge the injustice that so many are without the most basic access to palliative care. We work with many inspirational people - and there is great need. Thankyou for your support in this vision. What will your challenge be?

patient visits

I want to invite you to come with me on a couple of visits to the homes of patients. Perhaps you can try and imagine some of the sights and smells and sounds as we travel together. It is hot - more than 42 degrees today but our vehicle has AC. It was donated by the Friends of Vellore, UK. A family have called to say they are worried about their mother who is known to the team. She is very ill and in pain and they asked for help. It can be hard to know how to care for relatives at home without support. There are few comforts at the best of times and still so much fear about diseases such as cancer. Our patient was a lady in her 60's. She was clearly feeling miserable when we arrived - lying on a hard concrete floor, flies buzzing relentlessly and obviously in pain and distress. Our hearts went out to her and her family. Within a short time we were able to help her family wash her and bind her weeping sores. Advice and medication were given. Her son then helped fill a waterbed we had brought - an inexpensive but effective way to relieve pressure sores and give comfort. It was quite a challenge to find the right size of pipe and water funnel!! Meanwhile, the grandaughter had overcome her shyness of the foreign doctor and we were making friends. Soon many of the neighbours in the village had also joined. We left some time later tired and very thirsty but knowing we had been able to help. A drink of tender coconut juice on the way home was wonderful.

Let me take you down to Trivandrum now. I met this gentleman during a visit to the Pain and Palliative Care clinic jointly run by SUT Hospital and Pallium India. I was joining Prof Rajagopal and his team to help with some training programmes. this man lives in a small town 2 hours from Trivandrum. For the past week he has made a daily journey to the palliative care clinic. He has cancer of his mouth with a nasty open wound. Despite good care from his family he began to have worsening pain and swelling. The team have been treating him with analgesics, steroids and antibiotics but also spending time every day removing maggots - totalling more than 100 maggots. This is a distressing yet common complication of these wounds in a tropical climate. He is thankfully much more comfortable now and will be visited by the team at home. He spoke of his pain and his struggle with feeling 'unclean'. Like many patients, his pain is far more than just the physical.

It was great to meet Donald McNeil and Ruth Fremson from the New York Times who are researching the issue of morphine availability. It will be a fascinating story so look out for it.

hot, hot, hot

I realise that the UK had just had the warmest spell 'since records began' but I would love to open a quick window to Vellore and let you feel the heat. With the thermometer hovering around 38-40 degrees C, it is dry and dusty with any breeze circulating the air like a blast furnace. Rain is a welcome relief and washes the trees and shrubs till they sparkle and glow. A few days back we were treated to a spectacular thunder and lightening show and ran through the rain to get a better view. My partners in the madness were Dinesh (from New York) and Graham (chaplain from Adelaide) Here they are making puris one night for our supper!! It has been so lovely to share my time here with many some very special people - thanks to them all. Many have left recently - partly to avoid the worst of the summer heat; and we say our fond farewells. Here is Nita leaving - also a chaplain from Adelaide. The car is an Indian classic and is driven by our friend and driver, Suren. Many Indian friends are planning an escape to the hills too as the children are on their summer break.

One of the excellent projects we are involved with is a Distance Learning Module for Family Practitioners that has it's inspiration and leadership from Dr Vinod Shah. Some of you will recognise him from the days when he was the Director of the Emmanuel Hospital Association. This programme runs over 2 years and has 200 family doctors registered . A great achievement - and much of it due to the innovative and professional way the course is run by Dr Shah and his team. We are writing palliative care modules for year 2 of the course and I joined a writing workshop in Pondicherry. It is a great way to get a group of 'experts' together and some hard graft done - while also enjoying a few days away from the business of CMC. It was fun to explore the streets of this old French area - of course very much Indian now. We did manage some 'Gallic inspired' food and I have some cheese - a real find in India. This course has an important role - as so many Indian in rural areas rely very much on their local doctors. Referrals to hospital may be simply too expensive for many. The standard of practice and training of family doctors can be very variable. The course is also linked with many rural mission hospitals and will have the 'contact sessions' delivered in several locations. Having palliative care as part of the training will help take the philosophy and some knowledge and skill to new areas. Let us hope that in turn, many people and their families who are in need will find benefit and support. Remember, only 3% of the people in this vast and amazing country have access to pain relief at present.

I am off to visit Kerala for some training programmes now so will tell you more in my next post.

ps Dr Danjuma - lovely to hear from you. Let me have your email and I will write.

easter greetings

Sorry for being a week late with my Easter greetings! I was up at 4-30am on Easter Sunday to join a CMC tradition of climbing a nearby hill to watch the sunrise. It was very beautiful and moving to share communion together. I am nicely baking here in Vellore with temperatures around 38 degrees average. I am freezing my water bottles overnight so we can enjoy a cool drink most of the day and switching the fans up high. Think of the patients in the villages with no access to fans, fridges or even water at times!!

The Fellowship programme has now started and Dr's Vishnu and Ravi are the first students. They are both enthusiastic and settling well into the department. The other programmes for the education unit are all in progress and look innovative and exciting. We will also be contributing to an excellent distance learning programme for Family Medicine run by Dr Vinod Shah at CMC. I will only be able to offer support for 2 months this time though the team will be busy with clinical work and education developments over the summer. We are still waiting for some administrative issues to be sorted before the first patients can be admitted to the Hospice- that will be a red letter day!!

I also have a new bicycle as a gift from Reena and Pradeep. It is bright blue and named Miss India (as were all the others in the shop). I am having fun riding around campus starting with an early morning ritual to collect idly or dosa for breakfast. As a contrast, Rishi, Reena's wee son, now says haggis is his very favourite food. Even better than biriyani! How is that for cross-cultural exchange?
One tip - hold on to your biscuits though or a cheeky monkey might whisk them away - as happened to one small boy at church!!